CurrentBlue Cross Blue Shield - MainePolicy G-06018

Modifier 76 reimbursement

Defines Anthem Medicare Advantage reimbursement rules for services/procedures billed with modifier 76 (repeat procedure by same physician), including allowed use, required documentation, and non-reimbursable situations; applies to Anthem Medicare Advantage providers and facilities.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier 76 reimbursement

Policy CodePolicy G-06018

Change TypeAdministrative template update

Effective DateNov 7, 2016

Next Review Date

Key ActionProviders must submit supporting documentation for the use of Modifier 76 with the claim; claims without documentation will be denied.

SourceLink

POLICY UPDATE CHANGES

Updated policy template and removed 'Repeat Procedure by the Same Physician' from the policy title; definition of 'subsequent' removed.

100%nonsurgical reimbursement

2max repeated surgical procedures

0E/M or lab codes

1documentation required

Modifier 76 Coverage Criteria

Modifier 76 coverage criteria

Covered when ALL of the following conditions are met:

Anthem Medicare Advantage allows reimbursement for applicable procedure codes appended with Modifier 76 to indicate a procedure or service was repeated by the same physician.

Permitted submission contexts

Professional provider claims: when the repeated procedure or service is subsequent to the original procedure or service.
Facility claims: when the repeated procedure or service is on the same date as the original procedure or service.

Reimbursement rates and limits

For nonsurgical procedures or services: reimbursed at 100% of the applicable fee schedule or contracted/negotiated rate.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier 76 reimbursement

Policy CodePolicy G-06018

Change TypeAdministrative template update

Effective DateNov 7, 2016

Next Review Date

Key ActionProviders must submit supporting documentation for the use of Modifier 76 with the claim; claims without documentation will be denied.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Relevant Codes and Limits

ModifierModifierCovered

Modifier 76

Repeat procedure or service by same physician

Non-reimbursable code typesmixedNot Covered

E/M	Evaluation and management codes — not allowable with Modifier 76
Laboratory codes	Laboratory codes — not allowable with Modifier 76

Maximum reimbursed repeated surgical procedures

Maximum reimbursed repeated surgical procedures2 (surgical component only) — surgical component reimbursed at 100% of applicable fee schedule or contracted rate, limited to a total of two surgical procedures

Nonsurgical repeated proceduresReimbursed at 100% of the applicable fee schedule or contracted/negotiated rate

Assistant surgeon / multiple surgery impactIf repeated surgical procedure involves an assistant surgeon or multiple surgeries, assistant surgeon and/or multiple procedure rules and fee reductions apply

Pre/postoperative componentsModifier 76 not reimbursable for preoperative or postoperative components of a surgical procedure

Provider Documentation & Submission Requirements

Documentation Required

Submit supporting documentation or claim will be denied

Providers must submit supporting documentation for the use of Modifier 76 with the claim; if a claim is submitted with Modifier 76 without supporting documentation, the claim will be denied and providers will be asked to submit the required documentation for reconsideration of reimbursement.

Failure to attach supporting documentation will result in claim denial.
Providers may be asked to submit documentation for reconsideration after denial.

Billing Rule

Modifier 76 denotes repeat by same physician; use contexts

Modifier 76 indicates a procedure or service was repeated by the same physician and is allowed for professional provider claims when subsequent to the original procedure and for facility claims when repeated on the same date as the original procedure.

Professional claims: reimbursement allowed when repeated subsequent to the original procedure.
Facility claims: reimbursement allowed when repeated on the same date as the original procedure.

Definitions and Related Modifiers

Duplicate or Subsequent Services on the Same Date of Service — definition and related modifiers

Definition — Duplicate or Subsequent Services on Same DateDuplicate or Subsequent Services on the Same Date of Service = Modifier 91; related modifiers include 50/51 for multiple/bilateral surgery and 80/81/82/AS for assistant at surgery

Modifier 91Used to indicate duplicate or subsequent services on the same date of service (per general definitions)

Modifiers 50/51Referenced for multiple or bilateral surgery contexts

Modifiers 80/81/82/ASReferenced for assistant at surgery contexts

Non-reimbursable code typesModifier 76 is not allowed with E/M codes or laboratory codes (see non-reimbursable guidance) — avoid applying duplicate/subsequent modifiers to inappropriate code types